Module G: Denials and Appeals

CE Credits: 1.5


Coverage denials are a huge threat to a hospital’s revenue cycle. This module details how an organization can create a process to mitigate that threat as much as possible—by managing denials but also by preventing them. It begins by detailing the main causes for denials, and the common denial policies among large healthcare payers, such as Medicare. Next, it explores strategies that the transdisciplinary team can use to prevent denials, such as proper pre-authorizations and coding.

Learning objectives: After completing this module case managers will be able to:
» Discuss the denials and appeals processes
» Review Medicare, Medicaid and commercial payer policies
» Identify strategies to measure and monitor denials and appeals management
» Discuss a transdisciplinary approach to denials and appeals management


Advance your professional practice: Since there is a significant link between case management and the revenue cycle, case managers are well positioned to reduce denials and prevent unnecessary losses through such practices as clinical documentation review, understanding contractual limitations and being hands-on in the discharge-plan process.

Improve organizational performance: Denials can have a significant effect on a hospital’s bottom line. Managing denials and taking corrective action as soon as possible will not only save the organization a tremendous amount of time and resources, but can also help the organization maintain its financial health.